Intestinal Research

Usage of Narrow Band Imaging System in the Colorectum: Hiroshi Kashida; Intest Res 2009;7(1):1-7. Published online June 30, 2009

Abstract PDF: Narrow Band Imaging (NBI) is a novel technique that uses spectral narrow-band optical filters instead of the full spectrum of white light. As a result, superficial fine vessels and deeper thick vessels are demonstrated as brownish lines and greenish lines, respectively. This function enables detailed inspection of microvasculature of various kinds of gastrointestinal pathologies. Here is review of literature and present status of NBI in the endoscopic examination of colorectal lesions. There have been only a few papers concerning the usefulness of NBI for detecting colorectal polyps. The results were somewhat conflicting, but it seems that NBI has a possibility to enable beginners to detect polyps more easily. As for ability for tissue characterization, many studies demonstrated that NBI is useful for differentiating neoplasia from nonneoplasia; with or without magnification. Findings of magnified view with NBI are mainly analyzed in Japan and there are four major classifications of vascular patterns. Regardless of the classification system used, NBI was useful for differentiating between massively invasive cancers and less invasive lesions. Some authors have reported on their trial of utilizing NBI for the detection of ulcerative clolitis-related neoplasia. These reports suggest that NBI may render invisible endoscopic findings more visible without any dye solution, but the efficacy of NBI has not been proven yet. There is some possibility that NBI may replace chromoendoscopy, but a further study is needed to clarify which is more suitable, chromoendoscopy or NBI in the diagnosis of colorectal lesions. (Intest Res 2009;7:1-7)

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Clinical and Endoscopic Characteristics of Acute Hemorrhagic Rectal Ulcer and the Risk Factor of Rebleeding: Sung Han Park, Tae Oh Kim, Jung Nam Lee, Hyun Seok You, Dong Yup Ryu, Bong Yun Lee, Geun Am Song; Intest Res 2009;7(1):8-13. Published online June 30, 2009

Abstract PDF: Background/Aims
Acute hemorrhagic rectal ulcers (AHRUs) are rare and have not been thoroughly studied. This study aimed to assess the clinical and endoscopic characteristics of AHRUs and to determine the risk factors for rebleeding after the initial management. Methods: Thirty patients who underwent colonoscopy within 48 hours of the onset of hematochezia were consecutively enrolled between January 2004 and December 2007. The patients were divided into a rebleeding group and a non-rebleeding group according to presence of recurrent bleeding after initial management. We analyzed the clinical features, including the underlying disorder, the Karnofsky performance status (PS), the use of anticoagulant or antiplatelet agents, the endoscopic findings, and the methods used for hemostasis. Results: All of the patients were elderly, in a bedridden status, and all had experienced the sudden onset of massive, fresh rectal bleeding without pain. The characteristics of the lesions on colonoscopy included solitary or multiple rectal ulcers, or Dieulafoy lesions located in the distal rectum. There were no differences between the two groups based on mean age, gender, use of anticoagulant or antiplatelet agents, PS, methods of hemostasis, and clinical outcomes. The PT (INR) and endoscopic findings (Dieulafoy types), however, differed significantly between the two groups (p=0.024 and p=0.013, respectively). Conclusions: When massive hematochezia occurs in bedridden patients with severe comorbid illnesses, AHRUs should be considered in the differential diagnosis. It is advisable to be vigilant for rebleeding in patients with prolongation of the PT (INR) and Dieulafoy-type ulcers on colonoscopy.

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Clinicopathological Characteristics of Colorectal Cancer according to Microsatellite Instability: Ki Tae Suk, Hyun Soo Kim, Jin Hyung Lee, Bo Ra Kim, Moon Young Kim, Jae Woo Kim, Soon Koo Baik, Sang Ok Kwon, Yosep Chong, Mee Yon Cho; Intest Res 2009;7(1):14-21. Published online June 30, 2009

Abstract PDF: Background/Aims
Microsatellite instability (MSI) is associated with mutations in the DNA mismatch repair system and accounts for 10-15% of all cases of sporadic colorectal cancer (CRC). However, the characteristics and role of MSI as a marker for predicting the prognosis and therapeutic effect on CRC remain unclear. Methods: Between June 2003 and December 2007, 259 patients (males, 159 [61%]; age, 63 [±11] years) who underwent surgery for CRC were retrospectively enrolled. The clinicopathologic characteristics of patients with high-frequency MSI (MSI-H) CRC were reviewed and compared to patients with low-frequency MSI or microsatellite stable CRC. The patient characteristics and MSI-related data were recorded for the following variables: gender, age, clinicopathologic findings, chemotherapy response, recurrence, and survival. Results: MSI-H CRC was diagnosed in 30 patients (12%), low-frequency MSI CRC was diagnosed in 10 patients (4%), and microsatellite stable CRC in was diagnosed in 219 patients (84%). The MSI-H group exhibited the following characteristics: large size, right colon location, positive response to chemotherapy, low recurrence, longer survival, less neural invasion, poor differentiation, diffuse lymphoid reaction, and mucin pool formation. However, in the chemotherapy group (n=180), MSI-H was not a marker of longer survival. Based on Cox-regression analysis, stage IV CRC (OR=6.66; 95% CI, 2.24-53.00), MSI-H (OR=0.17; 95% CI, 0.04-0.73), and a positive response to chemotherapy (OR=0.02; 95% CI, 0.01-0.11) were related to mortality. Conclusions: MSI-H CRC had less neural invasion and diffuse lymphoid reaction. Further studies regarding the relationship between those pathologic findings and survival are needed. (Intest Res 2009;7:14-21)

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The Safety and Efficacy of Azathioprine and 6-Mercaptopurine in the Treatment of Korean Patients with Crohn's Disease: Hyun Ju Lee, Suk-Kyun Yang, Kyung-Jo Kim, Jae-Won Choe, Soon Man Yoon, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Jin-Ho Kim; Intest Res 2009;7(1):22-31. Published online June 30, 2009

Abstract PDF: Background/Aims
This study aimed to evaluate the adverse events and efficacy of azathioprine (AZA) and 6-mercaptopurine (6-MP) in Korean patients with Crohn's disease (CD). Methods: We retrospectively analyzed 700 patients with CD (male：female=469：231; median age at diagnosis, 22 years; agerange, 9-74 years) who were treated at the Asan Medical Center between January 1997 and January 2006. Results: Of 700 patients, 372 (53.1%) were treated with AZA/6-MP. The cumulative rates of AZA/6-MP treatment at 1, 5, 10, and 20 years were 17.4%, 51.6%, 73.1%, and 94.5%, respectively. Of 372 patients treated with AZA/6-MP, 217 patients (58.3%) experienced 291 adverse events, requiring discontinuation of therapy in 41 patients (11%). Nausea occurred in 120 patients (32.3%) and led to discontinuation of therapy in 11 patients (3.0%). Leukopenia developed in 116 patients (31.2%), requiring dose adjustments in 100 patients (26.9%) and discontinuation of medications in 16 patients (4.3%). Other adverse events included infections (2.7%), abnormal liver function tests (2.7%), fever (0.8%), hair loss (0.8%), arthralgias (0.5%), pancreatitis (0.5%), headaches (0.5%), and skin rashes (0.3%). Complete corticosteroids withdrawal was achieved in 70.9% of the patients based on an intention-to-treat analysis. The remission rate of perianal fistulas was 32.6%. Conclusions: The risk of leukopenia by AZA/6-MP is higher in Korean patients with CD than in Western patients. Although the adverse events of AZA/6-MP are not uncommon in Korean patients with CD, the actual discontinuation rate of the treatment is low. Therefore, AZA/6-MP can be administered to most Korean patients with CD without serious adverse events. (Intest Res 2009;7:22-31)

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Expression of Matrix Metallopreoteinases and Tissue Inhibitors of Metalloproteinases in Ulcerative Colitis: Seong-Eun Kim, Sung-Ae Jung, Ki-Nam Shim, Hye Kyung Jung, Tae Hun Kim, Kwon Yoo; Intest Res 2009;7(1):32-40. Published online June 30, 2009

Abstract PDF: Background/Aims
Ulcerative colitis (UC) is characterized by chronic non-specific inflammation in the mucosa and submucosa of the colon. Degradation of the extracellular matrix (ECM) is one of the major events during this process. Matrix metalloproteinases (MMPs) are important enzymes involved in the degradation of the ECM, and the activities of MMPs are controlled by its natural inhibitor, tissue inhibitor of metalloproteinases (TIMPs). This study was performed to determine the expression of MMPs and TIMPs in patients with UC. Methods: Twenty-nine patients with UC and 5 controls were included. Colonoscopic biopsies were obtained from the cecum, ascending colon, transverse colon, sigmoid colon, and rectum in each patient. The mRNA levels of expression of MMP-2 and -9, and TIMP-1 and -2 were measured separately using reverse transcription polymerase chain reactions in the mucosal specimens from each 5 segments of the colon. Results: The mRNA expression of MMP-2 and -9, and TIMP-1 in the inflamed tissues of patients with UC was significantly increased compared to non-inflamed tissues of patients with UC and controls (p＜0.05). The mRNA expression of MMP-9 and TIMP-1 in non-inflamed tissues of patients with UC was significantly higher than that of controls (p＜0.05). In inflamed tissues of UC, the mRNA expression of MMP-2 was significantly correlated with TIMP-2, and the mRNA expression of MMP-9 was significantly correlated with TIMP-1. The MMP-2/TIMP-2 ratio was increased in inflamed tissues compared to non-inflamed tissues of patients with UC and controls (p＜0.05). Conclusions: MMP-2 and-9, and TIMP-1 are likely to contribute to the inflammatory cascade in UC. MMP-2 and-9, and TIMP-1 might be important clues to solve the pathogenesis of UC. (Intest Res 2009;7:32-40)

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Inter-Physician Variation in Treatment for Patients with Crohn's Disease: Hwang Choi, Sang Woo Kim, Kang Moon Lee, Bo In Lee, Dae Young Cheung, Min Kuk Kim, Hyun Jung Jung, Hyung Keun Kim, Jeong Seon Ji, Soo Heon Park, Hiun Suk Chae, Myung Gyu Choi, Kyu Yong Choi, In Sik Chung; Intest Res 2009;7(1):41-46. Published online June 30, 2009

Abstract PDF: Background/Aims
The incidence and prevalence of Crohn's disease are increasing in Korea. However, the guidelines for the management of Crohn's disease have not been established in Korea. In the current study we determined the difference in the treatment methods between physicians in Korea for Crohn's disease. Methods: We retrospectively analyzed the use of medical and surgical treatment modalities in 92 patients with newly diagnosed Crohn's disease. We compared the treatment strategies among 4 physicians at 3 different institutions. Results: Prednisone, 5-aminosalicylates, antibiotics, immunomodulators, infliximab, and surgery were prescribed or preformed in 64%, 92%, 24%, 35%, 9%, and 22% of the patients, respectively. The surgical procedures included 12 bowel resections and 8 fistulectomies. The prescription rates for 5-aminosalicylates, prednisone, antibiotics, and infliximab did not differ, but of the use of immunomodulators was significantly different between physicians (p=0.012). The mean interval between diagnosis and the start of immunomodulators was 14 months, and was not different between physicians. The median dosage of immunomodulators was 50 mg per day, and was not different between physicians. Conclusions: A difference in medical treatment strategies for Crohn's disease between physicians exists in Korea. Specifically, there was a significant difference in the use of immunodulators between physicians. The development of treatment guidelines for Crohn's disease, together with efforts to decrease the inter-physician difference for treating Crohn's disease are needed. (Intest Res 2009;7:41-46)

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Clinical Characteristics of Primary Epiploic Appendagitis: Jae Jung Park, Sung-Ae Jung, Young Wook Noh, Go Heun Kim, Hyun-mi Heo, Suh Eun Bae, Yun Jung Choi, So I Kim, Myung-Won Lee, Min Jung Kang, Ji Min Jung, Seong-Eun Kim, Hye-Kyung Jung, Ki-Nam Shim, Tae-Hun Kim, Kwon Yoo, Il Hwan Moon; Intest Res 2009;7(1):47-51. Published online June 30, 2009

Abstract PDF: Background/Aims
Primary epiploic appendagitis (PEA) is a rare cause of focal abdominal pain in otherwise healthy patients. Patients with acute abdominal pain are often misdiagnosed clinically as acute appendicitis or diverticulitis. The purpose of this study was to describe the clinical presentation and characteristic computed tomography (CT) findings of PEA. Methods: We reviewed the clinical records and CT images of 23 consecutive patients in Korea who presented with acute abdominal pain between January 2005 and February 2009 and had radiologic signs of PEA. Results: Twenty-three patients (7 females and 16 males; average age, 42±14 years) were diagnosed with symptomatic PEA. Abdominal pain localized to the left (8 patients [44.5%]) and right (10 patients [55.5%]) lower quadrants as the leading symptom. CT findings specific for PEA were present in all patients except one. The symptoms resolved within 1 week (mean, 3.5 days) with or without antibiotic treatment. Conclusions: In patients with localized, sharp, acute abdominal pain not associated with other symptoms, such as nausea, vomiting, fever or atypical laboratory values, the diagnosis of PEA should be considered and the diagnosis confirmed by CT scan. (Intest Res 2009;7:47-51)

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A Case of Hemorrhagic Cerebral Infarction in Ulcerative Colitis: Eun Jung Choi, Byung Ik Jang, Kyung Ae Chang, Sang Hun Lee, Yong Kil Kim, Kyeong Ok Kim, Si Hyung Lee, Seok Jin Yoon; Intest Res 2009;7(1):52-55. Published online June 30, 2009

Abstract PDF: Ulcerative colitis is associated with a number of extraintestinal complications, including the infrequent occurrence of thromboembolic disease. Cerebral venous thrombosis is an extremely rare and fatal complication of ulcerative colitis. A 38-year-old woman presented with sluggish mentation and left hemiplegia. Ulcerative colitis had been diagnosed 3 years earlier by colonoscopy and biopsy, and had been controlled with a mesalazine. On admission, a brain computed tomography revealed a high density area in the right frontal lobe, and T2-weighted magnetic resonance imaging demonstrated an abnormal signal in the right frontal area, suggestive of a hemorrhagic cerebral infarction. She was managed with a decompressive craniectomy and conventional treatment for ulcerative colitis. (Intest Res 2009;7:52-55)

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Seven Cases of Epiploic Appendagitis: Retrograde Analysis of Clinical Characteristics: Young Chul Choi, Ho Jung Kim, Kwang Seok Kim, Yong Hyeon Jin, Uh Joo Lee, Hong Min Ahn, Tae Seung Lee; Intest Res 2009;7(1):56-59. Published online June 30, 2009

Abstract PDF: Epiploic appendagitis is a relatively rare cause of acute abdominal pain. Usually, epiploic appendagitis is a benign and self-limited condition, but it can be clinically misdiagnosed as acute appendicitis or diverticulitis, so an inaccurate diagnosis may lead to unnecessary treatment. We recently managed 7 cases of epiploic appendagitis during 1 year and review these cases with an emphasis on the clinical diagnostic features. The main pathophysiologic mechanism underlying epiploic appendagitis is thought to be triggered by appendageal torsion and caused by a subsequent blood flow disturbance. This medical condition must be kept in mind when a patient with acute abdominal pain has well-localized pain which is characteristically sharp in nature and a mild systemic inflammatory response compared to the severity of the pain. (Intest Res 2009;7:56-59)

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A Tuberculous Peritonitis Presenting as Submucosal Tumors: Chang Soo Choi, Geom Seog Seo, Ki Hoon Kim, Bong Joon Yang, Yong Hwan Ahn, Suck Chei Choi; Intest Res 2009;7(1):60-63. Published online June 30, 2009

Abstract PDF: Tuberculous peritonitis is not an uncommon disease, but the diagnosis is often missed and delayed because of the variability of disease presentation and non-specific clinical manifestations. In this report, we discuss a rare case of tuberculous peritonitis which presented as a submucosal mass in the colon. A 61-year-old woman registered at our hospital for a physical check-up. She had a weight loss of 3 kg over the past 6 months. The colonoscopic findings showed submucosal lesions (4 and 6 mm in size, yellow in color, and hard) which were suspected to be a carcinoid tumor. However, an abdomen-pelvic CT scan and laparoscopic findings suggested peritoneal tuberculosis. The result of laparoscopic biopsies was chronic granulomatous inflammation without caseous necrosis. After the standard anti-tuberculosis medications for 6 months, the previous lesions on the CT scan had resolved. (Intest Res 2009;7:60-63)

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A Case of Colonic Duplication Cyst Mimicking Gastrointestinal Stromal Tumor: Hee Chul Jung, Seok Won Jung, In Du Jeong, Sung Jo Bang, Jung Woo Shin, Neung Hwa Park, Young Min Kim, Dae Hwa Choi, Do Ha Kim; Intest Res 2009;7(1):64-67. Published online June 30, 2009

Abstract PDF: Duplications of the gastrointestinal tract are rare congenital malformations that are usually present during the first decade of life. However, a smaller number of cases may remain occult until adulthood. Overall, the colon is the least common site of congenital gastrointestinal duplications. Colonic duplications can present with symptoms of diverticulitis and can be confused with acquired giant cysts or masses. We present a rare case of a duplication cyst of the colon in a female adult. Although the preoperative evaluations, including an abdominal CT scan and colonoscopy, were suggestive of a gastrointestinal tumor of the colon, the final diagnosis was a colonic duplication cyst based on the histopathologic examination of the resected specimen. Even if intestinal duplication cysts are uncommon, they should be considered in the differential diagnosis of intestinal masses. (Intest Res 2009;7:64-67)

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A Pooled Analysis of Advanced Colorectal Neoplasia Diagnoses after Colonoscopic Polypectomy (Gastroenterology 2009;136:832-841): Soon Man Yoon; Intest Res 2009;7(1):68-70. Published online June 30, 2009

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Colorectal Cancer Expression of Peroxisome Proliferator-Activated Receptor Ճ Is Associated with Good Prognosis (Gastroenterology 2009;136:1242-1250): Bo-In Lee; Intest Res 2009;7(1):71-72. Published online June 30, 2009

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